87201A - Old, Jerry

�°`°"'"❑CAMA ❑DREDGE & FILL
GENERAL PERMIT
New ❑Modification ❑Complete Reissue ❑Partial Reissue
No 87201 A B C D
Previous permit
Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
I SA NCAC 0114 � I) C ) C? ❑ Rules attached. �General Permit Rules available at the following link: www.deq.nc.gov/CAMArules
Applicant Name -Sc- t r vt C AA Authorized Agent 1'Y /'-L,
Address PC::, 6 L) 1� t7 f� f-� Project Location (County): '0% r- I
City iJi n if r') C. `- State ZIP 219 `7 rri Street Address/State Road/Lot #(s) t 4� "I• C-.�� I} fdri•e^r•-+°•' '�? "� '>
Phone #(��t7tJ 2(.21- , e'O I oI s Cy . 1Z.c4 %Ir,e, t k�— =�•$r•,� tts t ,s-�ry
Email r 1r) 6� r, L)fr IIs) ['-L V1 OYY': !OYr'Y Subdivision A(rrr- Hrtl t- -Ii, tj 63!y iPSl!>y`,
City M r'%.� C_tc:, ZIP
Affected ❑ CW ❑EW ❑ PTA ❑ ES ❑ PTS Adj. Wtr. Body ..(l 1 13(1.4 (nat/man/unk)
AEC(s): ❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Mal. Wtr. Body i,( <. Y !1 ..r/ rl•i
ORW: yes'1no) PNA: yes/no
Type of Project/ Activity
Shoreline Lengthy
Access Length
Pier (dock) length
Fixed Platform(s)
Floating Platforms)
Finger piers)
Total Platform area _
Groin length/M
Bulkhead/ Riprap length
Avg distance offshore_
Breakwater/Sill
Max distance/ length
Basin, channel
Cubic yards
Boat ramp
Boathouse/ Boatlift l _
Beach Bulldozing r
Other I
SAV observed: yes no Iil I b11 e
Moratorium: n/a yes no T `
Site Photos: yes no - - . - r- - ` i
Riparian Waiver Attached: yes - no 11�_� _...
A building permit/zoning permit may be required by: U r r t T c1 L•.� C U V r A
Permit Conditions
❑ TAR/PAM/NEUSE/BUFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. (Please Initial)
Agent or Applicant PRINTED Name
Permit Officer's PRINTED Name
Signature *`Please read compliance statement on back of
Application Fee(s) Check Jt/Money Order
Signature
Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address: s�, 5
Phone Number: _252 20 1 •=-
Email Address: 34�
I certify that I have authorized
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at
in County.
I furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
C�7
Signa e
Print or Type Name
Title
L2, I_ I z / 2'>
Date
This certification is valid through

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner. I
Address of Property: !�- i Gr !f �5 A lze l,�-tell
Mailing Address of Owner: �'S cr,�---i� +Y�i�+-y "fg
Owners email: `i<'; n, .)n,r.,cv ba! s!"a' Owners Phone#: Z
Agent's Name:
Agent's Email:
Agent
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adiacent Property Owner)
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this
permit has described to me, as shown on the attached drawing, the development they are proposing. A
description or drawing with dimensions must be provided with this letter.
1,00 NOT have objections to this proposal. I DO have objections to this proposal.
Management (DCM) In writing within 10 days of receipt of this notice. Correspondence should be
mailed to 401 S. Griffin St., Ste. 300, Elizabeth City, NC, 27909. DCM representatives can also be
contacted at [phone]. No response Is considered the same as no objection if you have been
noted by Certified Mail.
WAIVER SECTION (Choose only one
I understand that any proposed pier, dock, mooring pilings, boat ramp; breakwater, boathouse, lit, or
groin must be set back a minimum distance of 15' from my area of riparian access unless waived by me
this does not a 1 to bulkheads or ri a revetments . (If you wish to waive the setback, you must sign
IF
appropriate blank below.)
100 wish to waive somelall of the 15' setback _.
Signature of Adjacent Riparian Property Owner
-OR-
1 DO NOT wish to waive the 15' setback requirement (initial the blank)
1"C
Signature
Typed/Printed name of ARPO✓✓II1110 $110771 IV-0 M'y, ..�
Mailing Address of ARPO: i a „'�K_ i()o Gu ✓' �`� �L ��� ��
Wbvu,-n16Y,919 vns.0lliw.�^
ARPO's email: ARPO's Phone#:
Date: 'waiver is valid for up to one year from ARPO's Signature*
Revised August 2022

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY
APR 1 6 2024
(Top portion to be completed by owner or their agent)
Name of Property Owner: iGRW,( Oki DCM-E ('."
Address of Property: LeT L a1A W ,,,,rs,:
Mailing Address of Owner: o . 13" -5,0 5 0c_K e. 7 -7958
Owner's email:.-Lo w am"ex Lmes Owner's Phone#: Z52 • 202 • 30o L
Agent's Name:
Agent's Email:
Agent Phone#:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom portion to be completed by the Adjacent Property Owner)
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this
permit has described to me, as shown on the attached drawing, the development they are proposing. A
I•DO NOT have objections to this proposal. I DO have objections to this proposal.
If you have objections to what is being proposed, you must notify the N.C. Division of Coastal
Management (DCM) In writing within 10 days of receipt of this notice. Correspondence should be
mailed to 401 S. Griffin St., Ste. 300, Elizabeth City, NC, 27909. DCM representatives can also be
contacted at [phone]. No response is considered the same as no objection if you have been
notified by Certified Mail.
WAIVER SECTION (Choose only one
I understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or
groin must be set back a minimum distance of 15' from my area of riparian access unless waived by me
(this does not apply to bulkheads or riprap revetments). (if you wish to waive the setback, you must sign
the appropriate blank below.)
I DO wish to waive some/all of the 15' setback
Signature of Adjacent Riparian Property Owner
-OR-
I DO NOT wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner:
Typed/Printed name of ARPO: P4tric % r, Zrjprreff- —
Mailing Address of ARPO: 7 n '12� r o t )b1Ty o_c k N G. 2 79s8
ARPO's email:
ARPO's Phone#: r;Z_Sa $
Date: A • $ ' 7-` 'waiver is valid for up to one year from ARPO's Signature*
Revised August 2022

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL • RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property Owner:- JX 0 g)
Address of Property: LOT C — u �— N uoe, (q fne it 5� &) w1s) CM
Mailing Address ofiOwner:, P01301 5-bL �0 04 P ',1JCg
Owners email: 110©��} I t�ktitwOc amwnees Phone#: 2- 2A� ?�bO j
J
Agent's Name:
Agent's Email:
Agent Phone#:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
(Bottom Portion to be completed by the Adjacent Property Owner)
1 hereby certify that I own property adjacent to the above referenced property. The individual applying for this
permit has described to me, as shown on the attached drawing, the development they are proposing. A
description or drawing with dimensions must be provided with this letter
_ I -DO NOT have objections to this proposal. I DO have objections to this proposal.
If you have ob)ectlons is what )s being proposed, you must notify the N.C. Division cf Coastal
Management (DCM) In writing within 10 days of receipt of this notice. Correspondence should be
mailed to 401 S. Griffin St., Ste. 300, Elizabeth City, NC, 27909. DCM representatives can also be
contacted at [phone]. No response Is considered the sarne as no objection if you have been
notified by Certified Mail.
WAIVER SECTION (Choose only one)
understand that any proposed pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or
groin must be set back a minimum distance of 15' from my area of riparian access unless waived by me
(this does not apply to bulkheads or dorap revetments) (if you wish to 4aive the setback, you must sign
the appropriate blank below.)
I DO wish to waive some/all of the 15' setback
-OR-
Signature of Adjacent Riparian Property Owner
I DO NOT wish to waive the 15' setback requirement (initial the blank)
Signature of Adjacent Riparian Property
Mailing Address ofARPO: tLi t le LPLi cry�(G 7�jS�
ARPO'semail: 1Q1d r.S QNCZ• ,Ccl-JARPO'sPhone#: Z5Z-8/(p- Z60/o
Date: 1.63 . M •waiver is valid for up to one year from ARPO's Signature`
Revised August 2022

12/12/23, 12:59 PM
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